Provider Demographics
NPI:1598778102
Name:MITTAN, DANIELLA MARIANA (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIELLA
Middle Name:MARIANA
Last Name:MITTAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1605 ROCK PRAIRIE RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-8358
Mailing Address - Country:US
Mailing Address - Phone:979-764-0107
Mailing Address - Fax:979-764-0173
Practice Address - Street 1:1605 ROCK PRAIRIE RD
Practice Address - Street 2:SUITE 301
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8358
Practice Address - Country:US
Practice Address - Phone:979-764-0107
Practice Address - Fax:979-764-0173
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23561207RE0101X
TXP1901207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287026Medicaid
ORH57477Medicare UPIN
ORR118301Medicare PIN